HomeMy WebLinkAboutNCC221000_FRO Submitted_20220310FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. Hidden Lake Lots 76, 85, & 86
1. Project Name
2
Location of land -disturbing activity: County Franklin
Highway/Street
Forest Bridge RdNLatitude
alebrook Ct 36.055
City or Township Youngsville
Longitude-78.444
3. Approximate date land -disturbing activity will commence: 4/1 /22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.11 aC
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Crawford E-mail Address acrawford@eastwoodhomes.com
Telephone 9197588208 cell # 9194272962 Fax #
E
Landowner(s) of Record (attach accompanied page to list additional owners):
Eastwood Homes of Raleigh, LLC (919) 758-8208 (919) 647-4183
Name Telephone Fax Number
6601 Six Forks Rd, Suite 100 6601 Six Forks Rd, Suite 100
Current Mailing Address
Raleigh, NC 27615
City State
10. Deed Book No. 2266
Current Street Address
Raleigh, NC 27615
Zip City
Page No. 390
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Eastwood Homes of Raleigh, LLC acrawford@eastwoodhomes.com
Name E-mail Address
6601 Six Forks Rd. Suite 100 SAME
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone 91975588208 Fax Number
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
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Sa JV1 a Notary Public of the County of `ice A-L2.
State of North Carolina, hereby certify that w)f'V� appeared
personally before me this day and being duly Jworn acknowledged that the above form was
executed by him.
Witness my hand an]r
q,pptgjal seal, this I day o 20
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